He is an 82 year old man with End Stage Renal Disease (ESRD) caused from longstanding Hypertension, Diabetes, and severe Peripheral Arterial Disease. He began hemodialysis treatment and was able to receive a renal transplant at age 74. Six years later, his body rejected it forcing him to continue hemodialysis. Shortly thereafter Mr. Tate had a stroke confining him to a wheelchair. His family soon noticed Mr. Tate withdrawing from them and becoming apathetic. They encouraged him to see a psychiatrist to which Mr. Tate agreed. He expressed his desire to quit dialysis, but explained he did not want to hurt his family. The psychiatrist encouraged Mr. Tate to talk with his family about his wishes. Mr. Tate's wife and daughter are very religious and express their desire for treatment continuation. His other daughter and son however, see their father's suffering and want to switch him to palliative care. Mr. Tate feels conflicted and simply stays quiet (Schumann & Alfandre, 2008).Melanie Gurski(Schumann & Alfandre, 2008)Melanie GurskiSystematic approach used to reach an ethical decisionCreated by Jonsen, Siegler, and WinsladeEach box contains a set of specific questions used to make a conclusion about a particular case.III Quality of LifeDefining the advantages and disadvantages of certain medical interventions by looking at certain patient characteristics; highly based on individual experiences and preferences (Potter & Perry, 2013).Melanie GurskiQuestions in the Jonsen model are based on ethical principles of beneficence, non-maleficence, and respect for autonomy (Cherry & Jacob, 2011).Mr. TateCase StudyMr. Tate desires to stop treatment. He is 82 with several comorbidities.(Schumann & Alfandre, 2008).Ethical DilemmaThe debate about the morality of euthanasia is not new, but dates back to ancient Greece and Rome (Gupta, 2006, p.167).The primary arguments are:Individuals have the right to death with dignity versus the moral acceptability of deliberately “killing” someone, even when done under certain detailed conditions (Begley, 2008, 436-437).

Right to self-determinationEnd unnecessary sufferingLegalization would not produce harmful consequences

PROSCONSSanctity of lifePossibility for abusePatients may feel pressured into the choice“Slippery slope” argument

(Gupta, Bhatnagar & Mishra, 2006)

Tanisha HowardTanisha HowardEvaluation of the medical factsGuided by the ethical principles of beneficence (prevent harm) and non-maleficence (do no harm)Healthcare providers use of clinical skills and knowledge to promote good patient outcomesTakes into consideration the risks/benefits of all planned interventions in order to mitigate negative patient outcomes

Tanisha HowardBeneficence & Non-malificenceWhat is Mr. Tate’s current medical problem?ESRD, PAD, DM and HTNIs Mr. Tate’s medical problem acute or chronic?Chronic and permanent conditionsWhat are the goals of treatment and the likelihood of success?To extend Mr. Tate’s life by continuing dialysisWhat are the plans in the event therapy fails?Discontinuing dialysis, providing palliative care, or assisting Mr. Tate with a “good death”

(Schumann & Alfandre, 2008, p. 37)

Tanisha Howard1.) The intentional and purposeful act of causing the immediate death of another person by discontinuing life-sustaining treatment is called:A.) EuthanasiaB.) Passive euthanasiaC.) Active euthanasiaD.) Physician-assisted suicide

2.) How much of healthcare costs are spent on end of life and palliative care? a.5-8% b.35-45% c. 10-12% d. 12-18%

3.) Which of the following statements best reflect the law in Oregon regarding euthanasia, which took place in 1977?

A.) Physicians can prescribe lethal medication doses to people meeting criteria.B.) It is illegal to assist any client in hastening their death under any circumstances.C.) Significant others may assist a client in hastening their own death.D.) It is illegal for a client to approach a physician about assisted suicide. (Ramont & Niederinghause, 2004)

Main consideration of this model A patient can have a living will discussing their end of life wishesAn informed consent would be signed before any procedure would be conductedPatients have the right to refuse treatment

AutonomyDefinition: A person’s ability to act and make decisions for themselves regardless of others influence (Butts, 2008). In short: Self DeterminationOur role as healthcare providers: We facilitate and support patient’s wishes with their treatment( Butts, 2008). Autonomy can only be restricted when a person poses harm to themselves or another person (Klein,2004).

Jamie DeludeThe patient has the right to end their life in the way they wish to uphold their dignity in death. Based on the idea of : one’s right to die in a manner of their own choosing” Autonomy: Is it hurting themselves or helping?(Chochinov, 2006)

Autonomy r/t Active EuthanasiaAre the mentally capable of making their own decisions?What is the patient stating about their preferences?Do they understand their treatment? Advance directives?Is the patient’s right to choose being respected

Autonomy in this CaseJamie DeludeMR. TATEHis Advanced directive prior to transplantChange of mind after rejectionWants what is best for his familyHe appears to be of sound mind and feels his death is near

Jamie Delude5.) Which of the following responses by a nurse would be appropriate to reflect the ANA’s code of ethics regarding active euthanasia?

A.) “Ok I’ will go get the doctor to set up the paper work for the leathal administration of medication”B.) “I know you are in pain and I want to honor your wishes to pass on, so I will go give you an extra dose of morphine to lower your respirations. C.) Tell the patient that they could make a full recovery and there are more reasons left to live. D.) Tell the patient you will make them as comfortable as possible but that she cannot administer any additional medication that could cause death.

What Nurses think about Active EuthanasiaMost studies that have been conducted deal with nurses in oncology, critical care and palliative careParticipants were asked about their willingness to assist with active voluntary euthanasia for an incurably ill patient if it were legal and at the patient’s request.Responses showed that 78.9% of critical care nurses, 56.2% of aged care nurses and 33.3% of palliative care nurses expressed willingness to participate in active euthanasia. Concluded nurses working in critical care or mental health are more willing to be involved in the provision of active euthanasia than those who work in aged or palliative care (Holt, 2008)ANA Code of Ethics

Jamie Delude(Schuman & Alfandre, 2008, p. 39)

4.) Which of the following countries have legalized euthanasia? Select all that apply.A.) NetherlandsB.) SwitzerlandC.) AustraliaD.) Belgium

Patients with appropriate decision making capacity authorize physicians to take their lives

Involuntary:

Physician is able to euthanize a person without their direct consent

Active Euthanasia:The intentional and purposeful act of causing the immediate death of another person, such as individuals with a painful disease, incurable disease, or a terminal illness 1973: American Hospital Association creates Patients Bill of Rights (gave patients the right to refuse treatment) 1974: First U.S. hospice opens in New Haven, Connecticut (Hillard, 2003)1976: NJ Supreme Court allows Karen Ann Quinlan’s parents to disconnect her respirator. She lives for an additional 8 years1976: California Natural Death Act is enacted1977: CA, NM, AK, Na , ID,OR, NC, and TX have a right to die bill1998: Doctor Death is aired on CBS1999: Dr. Jack Kevorkian is Convicted of Murder2005: Terri Schiavo has her feeding tube removed2013: VT, OR, WA, MT- allow Physician-Assisted Suicide(Hillard, 2000; Woodman, 2001; Haigh, 2013)

“All clinical encounters occur in a broader social context beyond the physician and patient, to include family, the law, culture, hospital policy, insurance companies and other financial issues” ("Ethics in medicine," 2013)Family BurdenCost implicationsAllocationImplicationAvailable resources

Contextual Factors: Pros/ConsPROSFrees up medical funds to help others -End of life care is 10-12% of total healthcare costs -25-30% of Medicare program benefits are spent on care at the end of life(Jennings & Morrissey, 2010)Provides family members financial and emotional relief from the burden of taking care of a dying loved oneAllows patients to die with dignity

CONSPotential to become a means of health care cost containmentCoercion of dying patient by exhausted care-takersCoercion in the hopes to free up benefits such as life insurance and inheritanceDevalue human life

Stephanie LamartineCASE STUDY: Contextual FactorsFamily dynamics:-Son is the major caregiverSenses that Mr. Tate no longer wants to continue dialysis and is ready for death

Primary care physician obtains medico-legal opinion on the precedent and lawfulness of dialysis discontinuationCost of palliative care/ hospice is low when compared to cost of continued aggressive treatment and Mr. Tate’s frequent hospital visits

Stephanie Lamartine• What does the patient want?-He desires to discontinue dialysis• He is in a tremendous amount of pain• He feels that his quality of life has been lessened• He is mentally competent, but conflicted• There can be no resolution until Mr. Tate is able to initiate an open, honest discussion with his family and decisively express his feelings of wanting to die with dignity– He wants “what is best for the family,” and yet is also ready to die in peace at home6.) Which of the following states have laws approving the practice of physician-assisted suicide? Select all that apply.A.) OregonB.) WashingtonC.) MontanaD.) Illinois

7. Which of the following is associated as a “pro” for active euthanasia? a. End unnecessary suffering b. The “slippery slope” argumentc. Sanctity of lifed. All of the above are pros

8.) Which of the following is not an influential case in the euthanasia debate? a. Quinlan’s Trials b. Dr. Kevorkian Trials c. Terri Shiavo Trials d. All of the above are important trials